What is the treatment for acute otitis media?

Treatment of Acute Otitis Media

High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses) is the recommended first-line treatment for acute otitis media in most patients due to its effectiveness against common pathogens, safety profile, low cost, acceptable taste, and narrow microbiologic spectrum. 1

Diagnosis Criteria

Before initiating treatment, confirm the diagnosis of acute otitis media (AOM) by verifying:

1. Acute onset of signs and symptoms
2. Presence of middle ear effusion
3. Signs of middle ear inflammation
4. Symptoms such as pain, irritability, or fever 1, 2

Treatment Algorithm

First-line Treatment:

• High-dose amoxicillin: 80-90 mg/kg per day in 2 divided doses for:
  • Children <2 years: 10-day course
  • Children 2-5 years with mild/moderate symptoms: 7-day course
  • Children ≥6 years: 10-day course 1

Alternative First-line Treatment (specific situations):

• Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) for:
  • Children who have taken amoxicillin in the previous 30 days
  • Patients with concurrent conjunctivitis
  • When coverage for M. catarrhalis is desired 1

For Penicillin Allergy:

• Non-type I hypersensitivity reactions:

  • Cefdinir (14 mg/kg/day in 1-2 doses)
  • Cefuroxime (30 mg/kg/day in 2 divided doses)
  • Cefpodoxime (10 mg/kg/day in 2 divided doses) 1

• Type I hypersensitivity reactions:

  • Clindamycin (30-40 mg/kg/day in 3 divided doses) 1

Treatment Failure (symptoms persist after 48-72 hours):

1. Reexamine to confirm AOM diagnosis
2. If initially treated with amoxicillin, switch to:
   • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
3. If initially treated with amoxicillin-clavulanate, consider:
   • Ceftriaxone (50 mg IM or IV daily for 3 days) 1

Second Treatment Failure:

• Consider tympanocentesis for culture and susceptibility testing
• If tympanocentesis not available, consider:
  • Clindamycin (with or without a third-generation cephalosporin)
  • Consult with otolaryngology or infectious disease specialist 1

Pain Management

Pain management should be addressed regardless of whether antibiotics are prescribed:

• Acetaminophen or ibuprofen for pain relief
• Topical analgesics may provide additional relief 1

Observation Option

In certain cases, observation without immediate antibiotics may be appropriate:

• Children ≥6 months to <2 years with non-severe illness and uncertain diagnosis
• Children ≥2 years without severe symptoms
• Reliable follow-up must be assured
• Provide analgesia and reassess in 48-72 hours 1

Follow-up Considerations

• Routine follow-up visits are not necessary for all children with AOM
• Consider follow-up for:
  • Young children with severe symptoms
  • Children with recurrent AOM
  • When specifically requested by parents 1

Common Pitfalls to Avoid

1. Misdiagnosis: Differentiate AOM from otitis media with effusion (OME), which does not require antibiotics 1, 2

2. Overtreatment: Persistent middle ear effusion after successful treatment is common (60-70% at 2 weeks) and represents OME, not treatment failure 1

3. Inadequate dosing: Using standard-dose amoxicillin may be insufficient for resistant S. pneumoniae; high-dose is recommended 3

4. Inappropriate second-line choices: When amoxicillin fails, trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole are not appropriate due to high resistance rates 1

5. Neglecting pain management: Pain relief should be addressed regardless of antibiotic prescription 1

The treatment approach should consider the increasing prevalence of antibiotic-resistant pathogens, particularly penicillin-resistant S. pneumoniae and beta-lactamase-producing H. influenzae, which are the main reasons for treatment failure 1, 4.